Orientation refers to the therapist or counselor’s theoretical understanding. In other words, what are the theories, principles, or research that guide the therapeutic process. Theoretical orientation can cover the types of interventions that are used, an understanding of how someone grows healthier, or even the process by which someone develops difficulties.
There are massive amounts of theoretical models in the psychotherapeutic world, but they are all generally grouped into two categories: Psychodynamic and Cognitive Behavioral. Trying to truly spell out the differences between these two categories is beyond the scope of this article as there are a great many variations in theory, practice, and the individual way that each therapist or counselor practices, but I will attempt to provide some clarity.
Cognitive Behavioral Therapy (CBT) tends to be more short-term and solution focused. Cognitive therapy asserts that our emotional difficulties stem from cognitive distortions. These distortions manifest themselves in automatic thoughts that are triggered by situational events. Core beliefs about ourselves or our world tend to be the source of these automatic thoughts. For example, the core belief that I am a failure will produce automatic thoughts like “I’m a loser” if I don’t answer a question perfectly. So the CBT therapist would work on the core beliefs and automatic thoughts by challenging them. In addition, the behavioral aspects of the therapy involves techniques like exposure therapy and relaxation- creating experiences that help desensitize or control emotional responses and triggers.
Psychodynamic Therapy has considerably more variations to it, but it tends to focus more on the relational aspects of therapy. Some schools of thought see a person’s difficulties as related to emotions, thoughts, or impulses that are defended against, others work with the way in which an individual attaches to others, some look at how an individual handles his or her aggressive or sexual drives. Again, this is nowhere near an adequate explanation or exhaustive explanation of the variations involved in psychodynamic therapy. In short, this form of therapy looks at relationships and/or defenses with regard to how they provide difficulties for the individual. Generally speaking, it goes beyond looking at thought patterns as the source of an individual’s difficulties and the target of therapy.
The difficulty is that more and more individuals are describing themselves as Eclectic, which means they employ a variety of methodologies and theory, often a combination of Cognitive Behavioral Therapy and Psychodynamic Therapy. The difficulty is that the term eclectic says almost nothing about the therapist’s point of view or methodology.
Another overarching category that has emerged is Integrative. It is gaining a little more prominence over Eclectic and is the orientation that best describes my work. For a more detailed description of my theoretical orientation click here: The Counseling Process. Those with an Integrative orientation are not just combining various theories or interventions where appropriate, but are actually attempting to integrate various theories into an overarching theoretical orientation. In other words, those who are Eclectic may use CBT techniques in some situations and Psychodynamic in others, but Integrative therapists would see both the CBT and Psychodynamic techniques as following a consistent treatment informed by a diagnosis, conceptualization, and treatment plan that understands the individual’s difficulties as having cognitive and psychodynamic origins, as well as conceptualizing the treatment itself in a combined formulation of both CBT and psychodynamic understanding. Integrative therapists may integrate several types of Psychodynamic theories as well as certain Cognitive or Behavioral strategies.
There are many articles that will recommend a particular type of therapy for particular issues. The reality is that there is no way to accurately make that assessment. Anxiety is not treated more appropriately by CBT or Psychodynamic Therapy. There is not necessarily a right treatment, but a right therapist. I recall a young man that I saw who was experiencing great social anxiety. He had been part of several therapeutic interventions including a behavioral group for those with social anxiety and nothing was working. As we met, we discovered that there was a great deal of anger over the pressure he felt from others to change in order to be accepted by them. During the previous social anxiety group, he found himself shutting down because he was feeling pressure to perform. He was unaware that he was reacting to the same pressure he consistently feels around people in general. It was not a simple matter of feeling more comfortable around people, but working on some of the deeper issues. Now a therapist from many different orientations could have helped him. But it took someone who was willing to listen, not jump to conclusions and not apply a theory too quickly. To help him, required a knowledge of why people do what they do and an ability to ask the right questions and form a strong alliance. That of course is the beginning, to work through the issues is a bit more complicated but I provide this example to illustrate the idea that there is a specific treatment for specific issue. Social anxiety is not always best dealt with by attending a social skills/social anxiety group, but for some it can be very helpful.